Add new comment

Ten year old Vibha Kumari looks like any Delhi school girl. Except that a clean but well- worn old handkerchief masks her young face. For Vibha has multi-drug resistant TB - or MDR-TB - caused by a strain of bacteria that has developed resistance to the first line of antibiotics.

Vibha’s is a classic case of drug-resistant TB. Two years ago, when she had a terrible cough that just wouldn’t go away, she was treated by a village doctor at home in Bihar. When she didn’t get any better even after eight months of treatment, the family moved to Delhi where her father sold drinking water on the teeming streets of the city.

Moving into a one-room tenement in an overcrowded urban slum – where large families share small badly-ventilated rooms in conditions that are ripe for the infection to spread –Vibha was tested for TB. When MDR TB was found, probably as a result of inappropriate treatment in the village, she was put on the second line of drugs for a two-year course of treatment.

Vibha now has to come into the free TB clinic every morning to swallow a fistful of pills in front of a technician and take a painful injection. In the two months since her treatment began, she has begun to feel better.

The drug costs alone are over several thousand dollars for an effective course of MDR-TB treatment. Luckily for Vibha’s family, these costs are met by India’s national TB control program. For with five members to feed on a paltry income, they could barely make ends meet let alone afford expensive medical care for their young daughter.

Given the huge costs of diagnosis and treatment, the emergence of MDR TB poses a tough challenge indeed for Indian government. According to the World Health Organization (WHO) around 64,000 cases of MDR-TB are found among the 1.5 million cases that are notified by India’s TB program every year.

So far, the program has provided care to almost 9,000 MDR-TB patients. Over the next five years, it plans to significantly scale-up the number of patients it reaches. This will help prevent transmission of multi-drug resistant strains of the disease. However, as Vibha’s case shows, it is only by improving the care of first-line TB patients that will prevent further emergence of drug-resistance.

For this, it is crucial that the program scale-up its engagement with the private sector. While around two-thirds of the estimated new TB cases every year are reached by the national program’s Directly-Observed Treatment, Short-course (DOTS) – supported by the World Bank - the rest seek care in the private sector where the quality of diagnosis and treatment varies widely, and patients and their families must bear the cost. And without regular monitoring, once a person starts to feel better, he or she often stops purchasing the necessary drugs, leading to interrupted treatment and sometimes the development of drug resistance.

During its next phase (2012-17), at the same time that the program expands the response to MDR-TB, it will scale-up its engagement with private health care providers to contribute to prevention of drug resistance in the first place. The regulation and control of diagnostic tests and TB drugs in the market will also need to be improved. The government has requested additional World Bank support to this next phase.

Confronting this variety of challenges will be necessary to prevent many other families from experiencing the hardships that Vibha and her family have gone through.